To Screen or Not to Screen for Cancer (11/5/12)
Who would not wish to prevent cancer? When President Nixon started the “War on Cancer,” hopes were high that cancer screening would dramatically lower cancer incidence and death.
It did not work out that way.
Now, researchers often wonder how much screening benefits hospitals and providers – compared to patients. In his book “Ovediagnosed ” Dartmouth’s H. Gilbert Welch reviews many different screening programs. He was particularly interested in Norwegian data on mammography. Some women were screened for breast cancer every year, some every five years.
Those screened every year had 20% more tumors than those screened at five years. The conclusion: a fifth of the “tumors” seen on mammograms were spontaneously remitting – just going away.
As the body reinvents itself, nothing stays the same. Tumors appear, disappear, are walled off, come back. So when should one screen?
Let’s look at two recent controversies – breast and prostate cancer screening.
Breast Cancer Screening
British reports from recent, large government research programs reported by the BBC have recently declared that for every “life saved” by mammography, three people will be treated unnecessarily. The large majority of those who will undergo surgery, chemotherapy and radiation who will not benefit with increased lifespan.
Not everyone is confident in this data. One Danish researcher, Professor Gotzsche , believes the numbers are more like 10 to 1 – ten people treated for each life saved. He believes mammography is unnecessary – functionally useless.
Welch, who has surveyed the data for decades, thinks mammograms are somewhat useful. However, women who assess themselves monthly examining their own breasts do as fine a job screening as mammography.
What Has Changed With Prostate Cancer?
Quite a lot. Recent government data has argued that the very common PSA (prostatic serum antigen) test should not be used for screening in most men, and not after the age of 70. The developer of the PSA believes it has been profoundly overused.
A national blue ribbon committee in this country concluded that 30-50 men are treated unnecessarily for every life saved via the PSA. Welch argues that there is quite a lot of Scandinavian data showing the number as more like 100 treated for every single life saved.
This is not a new debate.
My father and his older brother died of prostate cancer at the same age of 83. Everything else about their disease course was different.
My uncle was the retired head of the California Tumor Registry. As a statistician who spent his working life looking at cancer statistics, he decided several decades ago that PSAs were not helpful.
He did not get screened.
When he developed prostate cancer it had already metastasized. He died soon thereafter.
My father had rising PSAs over years, with biopsies showing tumor at age 73. In good physical shape, he opted for radiation.
The radiation did not destroy the tumor.
His PSAs never went to zero. He was placed on a variety of treatments, mostly hormonal. He hated their effects, which put him through a male version of menopause and great fatigue.
Later on CAT scans were thought to show “lung metastases”. At this point a well known academic took over treatment and put him on PC-SPES, a combination of Chinese herbs. They appeared to help – for a while.
Eventually his PSAs went higher. The professor decided on a new technique, cryosurgery (freezing) that he was helping develop. At the end of the operation he proudly announced that he had “got all the tumor.”
He got more than that. The urethra was now necrosed, non-functional. Parts of the bowel were killed. My father was forced to wear a clamp to control urination the rest of his life.
And it was for naught. Tests that might have been done pre-surgically showed metastases that should have precluded surgery. My father’s formidable will to live was markedly decreased by the clamp and the continuous pain and discomfort which contributed to his death. The “lung metastases” were thought by other clinicians to have been entirely unrelated to the prostate cancer; they never changed with treatment.
The Right Thing To Do
Would my father have died at the same age of his brother regardless of early treatment? It’s hard to say. Under present treatment options, he would have avoided care that markedly changed his life.
And that is the conundrum of screening. What works for populations will not necessarily work for individuals.
Prostate cancer is less “environmental” than most. Diet and exercise have much less impact on its eventual course than many other tumors.
And treatment has changed as well. Dr. Snuffy Meyers, then head of the University of Virginia Cancer Center, was more or less “left for dead” by his colleagues when he found himself with metastatic prostate cancer at age 58. He is very much alive now, and has pioneered treatment with ketoconazole and other agents for people like himself.
So screening must be individualized. For its sometimes painful results which can include:
1. Unnecessary treatment for many.
2. Severe side effects of treatment.
3. Fear and dread brought by worry about the results of screening.
4. Huge costs in time, money, and family needs brought on by unnecessary treatment.
The issue is health, not health care. Screening is too often driven by monetary and commercial concerns.
Health – the greatest good for the greatest number – meaning well-being in physical, mental, social and spiritual arenas, should be foremost.
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